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Tuesday, December 11, 2012

MiM Mail: The what-ifs

Ever had one of those cases where you look back and just wish you'd done
things differently? What's your way of handling this feeling? Might you
be willing to share your moving forward strategy?

I'm an anesthesiology resident transitioning back to work from maternity
leave. While I love what I do, there have been quite a few days when I
definitely feel that the transition back to work is not as fast as I'd
like. The days where I feel like I'm relearning things I used to know.
Yes it's kind of like riding a bike after you haven't been riding one in
a while, but when you're training, sometimes you don't feel like you
ever really knew how to ride it that well even. And I have many moments
where I am mentally kicking myself because I just remembered something I
should have done or handled differently.

[The case below has been changed to protect patient and staff confidentiality]

For instance, recently there was a code blue at the hospital. A man who
had been undergoing a line insertion was now having massive hemoptysis. A
double lumen tube was inserted to isolate the bleed. Some air seemed to
be entering one lung. The PAC balloon is inflated and the hemoptysis
seems to have stopped for a while. The patient seems relatively stable
with good sats and bp and the patient's main physician consults ICU to
take the patient for close observation. At the back of my head is this
niggling feeling as I am not quite sure whether this tamponade from the
PAC balloon will hold - should we consider if we need a surgeon to sew
up whatever's bleeding? But soon, the patient is bleeding again, CPR is
started, the surgeon shows up but the patient is too unstable and
despite best efforts, the resuscitation is unsuccessful. When I get back
home, I read up on this, and more questions fill my thoughts. What if
we'd gotten a cardiothoracic surgery consult much earlier on? Or
heart-lung bypass? But now it's too late for the what-ifs and
should-haves. I just wished I had known more at the time to be more
useful.

Shortly after, I was in a simulator session. While I was fast on initial
management managing a crashing patient and securing the airway, I got
hung up on troubleshooting ventilator equipment that had failed, without
moving on to switching my equipment. It was one of those
how-stupid-of-course-I-should-have-thought-of-that moments - if
something's not working, sometimes the best option is not to try and fix
it, but to switch it entirely. I know that! But hadn't done it fast
enough. In a simulator, it's not a real patient crashing and that's
great. But if this was a real-life situation, that patient may not have
been as good.

I find it hard not to mentally kick myself, or to look with envy at
other colleagues and wonder how they seem so much more confident and
competent. When I look at my flubs, I often feel like a Bridget Jones
while others seem like a Grace Kelly or better yet a MacGyver - always
there with the best plan in the nick of time, executed with calm and
grace.

I hope I'm not the only one out there who has felt this way - trying my
best but feeling incompetent or stupid at times. Yes it is a learning
opportunity, and yes, I hope it gets better, and yes I feel I know more
than I used to - but when does one start to feel confident and
competent, and bring-it-on-because-I-can-handle-it rather than
I-hope-I'm-seeing-bad-stuff-when-there-is-someone-else-on-who's-better-than-me-there-to-guide-me-through-it?
When I was a med student, I looked at the residents with awe for their
competence and confidence, and now that I'm the resident, I don't know
that I feel that way.

Have you ever felt this way? Have you ever had cases that didn't go as well as you'd liked? How did you handle it?

10 comments:

Um, yeah, all the time, it's called being human. I'm just not sure men (stereotyping here) express it or even get hung up on it. I do notice it more now but I don't know if that is because I'm a mom now or further along in my career or just weighted down (aka more aware) by my responsibility.

Hi Susan, Thanks for writing! Your response mad me laugh out loud. I do wish I had more of that ability to not be hung up on it. How do these other people (men or women but I agree more men than women) do it? It's getting better with more knowledge, there is less second guessing. RLMD

Um, yeah, all the time, it's called being human. I'm just not sure men (stereotyping here) express it or even get hung up on it. I do notice it more now but I don't know if that is because I'm a mom now or further along in my career or just weighted down (aka more aware) by my responsibility.

Um, yeah, all the time, it's called being human. I'm just not sure men (stereotyping here) express it or even get hung up on it. I do notice it more now but I don't know if that is because I'm a mom now or further along in my career or just weighted down (aka more aware) by my responsibility.

All. The. Time. I compare myself to colleagues who haven't had a break for motherhood, or who don't work part time, and when I see them handle a situation, I feel I wouldn't have handled it as well. I worry because I'm on the mummy track - the one where I haven't devoted every waking minute to medicine, and where I've taken maternity breaks. I do worry that my knowledge is not as up to date as theirs. But then I try to look at the evidence, to see if there is any to support my feelings of incompetence, and I can't find any. My consultant once said, there are 4 stages of learning. The first stage is not knowing anything and feeling like you know nothing. The second stage is not knowing enough but feeling like you know everything. The third stage is knowing that you don't know everything and being aware of what you don't know, or how you could have handled something better, and the last stage is competence. Based on this, being aware of what you don't know simply means you are further along the learning pathway, and are aware of what you don't know, which makes you safe. Not surprisingly, the second stage is the most dangerous. So hang in there. Given time, you'll move onto the fourth stage, and that feeling will pass for most of the time. The remaining times, it's there to remind you to continue your learning.

Dear Aussie Mum,Thanks for this post. The 4 stages of learning is a neat concept. Things seem to be better the more knowledge I gain - not that I feel I know everything but more that I feel comfortable with what I do know and have a way of handling what I don't so it's still safe for the patient. It will be nice to be competent completely but I guess that's why residency is a five year process.RLMD

It took me a few years into private practice to feel like I had reached Aussie's level 3/4 (I believe they are one in the same) and there are still days when I have a really tough case or when I wake up on the wrong side of the bed that I feel vaulted back into Stage 1 (at least the feeling like, not the actual). I don't think I ever was in Stage 2 - that is not in my personality make-up, but I have seen it in others and agree it is dangerous.

Being a new mom is a big experience with a steep learning curve. Coming back from maternity leave in residency was tough - there were things to re-learn, even if you do not go on mat leave I think this is true. You get something new out of old information when it is presented again based on experience. I remember being called out as a dunce occasionally during residency - related to maternity leave? I think not, but there are attendings that have this belief and don't let them project that onto you. You are generally at least as competent (or more so!) than those around you in your training level, maternity leave or no.

Being a resident/med student creates long term emotional stunting, I believe. Having an attending above you is a comfort and a boon for confidence. There are some that fake confidence well in the process of being a resident, and I was not one of them but I did learn how to project it better because an under confident person opens him or herself up for attack, no matter what their knowledge base is. It wasn't until I got out into private practice and developed relationships with colleagues that were equal, and not subservient, that I finally felt better about my own decisions. Experience is also key.

Second guessing yourself in medicine is natural and good - we should always have that in us in order to serve patients well, as long as it doesn't make us crazy. There have been many cases that I was sure of, showed a colleague, and he or she agreed. But there are also cases I have been pretty sure of, showed a colleague, and their opinion differs from mine. Sometimes I'm right, sometimes they are. Those tough cases are the ones that stick in my head, and make me a better pathologist when the next one comes along.

RLMD you pay such good attention to other areas of your life I am certain you have potential for success here - good luck.

Thanks so much Gizabeth for your comment! I really appreciated it and have been reflecting on what everyone has said over the last few months. Experience, as you say has been key and even in the few months, it's been getting better the more one knows the more one can be confident and even more comfortable with the grey zones and the decisions one makes in those times. I have noticed that some people are more able to project confidence, and I too find that it's better to project it by trying to concentrate on the things one can get right or what one does know instead of worrying so much about the things one doesn't that it clouds the things one know. But getting to a point where one knows something well is gratifying - and I am so glad that you shared your experience with me - about how it can take years before one is confident even as an attending. just knowing that someone else had similar feelings makes me feel better.

What you are feeling is totally normal both in residency and out. I don't believe that you feel this way only because of your maternity leave. I went through anesthesia residency sans kids, and I felt like you many times. Know it's normal, let it motivate you to study hard, and push on. And studies show this kind of doubt affect women more. So keep your head up high and know you are smart and deserve to be there as much as the guy next to you.

I really like this book: Women Don't Ask: The High Cost of Avoiding Negotiations--And Positive Strategies for Change. It may help you through these questions and help you when you look for a job. Good luck!

Thanks so much Buttonchop for this input. I'm looking into the book right now and it sure has some neat things! It makes me feel better that other people like you have been through this and feel the same way.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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